Bill (not his real name) is a knowledgeable resident, sure about his goal to do the right thing for the patient.

I was supervising him in clinic today. We were talking about the patient, a lady in her 70s who had survived cancer but was somehow still well enough to be a primary caregiver for her grandchild. I saw the child gamboling in the hallway -- bright-eyed and fleet footed in a sequined shirt. Not a kid forgiving of malaise.

"So there's a bunch of stuff she should do but hasn't," said Bill. "She had some thyroid nodules found incidentally. Her thyroid tests were normal, and I don't see anything on exam, but she should follow up on--"

I was impatient, I admit. "Do we know it would be better for her to follow up on a small thyroid nodule, or prioritize her other conditions?"

"Well, anyway," he continued, half acknowledging my objection and half laughing it off. "She should be on a statin."

"Or you should ask her whether she wants to be," I countered.

"But I know I am doing the right thing for her."

"Do you know her preferences? We doctors are not good at guessing such things."

"She'll do whatever I want," he said. He meant it, but even as he said it, I am sure, he knew what it sounded like.

Such an attitude is all too common. And while I spend a lot of time thinking about and teaching patient-centered care, it still feels like a steep uphill climb when someone is not already one of the converted.

And the worst of it is - the hierarchy rules. He is right. The patient would probably have done what he said. Or at least, been unable to object.